Welcome to my blog. HIV prevalence is not a reliable indicator of sexual behavior because the virus is also transmitted through unsafe healthcare, unsafe cosmetic practices and various traditional practices. This is why many HIV interventions, most of which concentrate entirely on sexual behavior, have been so unsuccessful.

And the Vatican doesn't care whether STI rates or unplanned pregnancy rates are reduced as long as no 'sins' are seen to be committed in the process. But in most Catholic countries, especially rich ones, people take little enough notice of the preachings of the church.

The two institutions have a lot in common. They are both massively wealthy, unelected and virtually unaccountable, packed with some of the most educated people in their field, slow to change and often utterly oblivious to what goes on in the outside world.

The invitation of Dr Michel Sidibe, executive director of UNAIDS, to speak at a conference at the Vatican is seen as significant because the Vatican "usually only invites like-minded outsiders to its conferences and UNAIDS has not been like-minded on this issue at all".

I think that's an exaggeration. Sidibe may have come down on the side of condoms and stressed abstinence and marital fidelity a little less, while the Vatican has stressed abstinence and marital infidelity more and appeared to rail against condoms.

But both parties wish to influence the sexual behavior of poor people and seem hell bent on doing so. Both Sidibe and the pope know that talk about abstinence and marital fidelity are just talk. So far, UNAIDS have made do with putting a brave face on the results of their 'prevention' programs and the Catholic church has long had to put up with keeping the lid on reality.

Let's face it, neither institution has really aimed to reduce HIV transmission very convincingly. Both have done everything in their power to protect their own interests, although those interests are not always completely clear.

In truth, condoms are about all we have to reduce sexually transmitted HIV. There is a lot of talk about other measures, microbicides, pre-exposure prophylaxis, treatment as prevention, circumcision and probably a few others. But all of these are recommended in conjunction with the consistent and correct use of condoms.

Catholics have long ignored the pope's pronouncements about certain things, including contraception, abortion, homosexuality, pre-marital sex and much else. Even many of the popes own leaders have been shown to enjoy a varied sex life, even if their ways of expressing their sexuality might not be so popular among their followers.

If the technocrats and multinationals are even close to being right in claiming that one or several of their offerings will one day significantly reduce HIV transmission, at least in certain contexts, the two mammoths may even be able to publicly agree on things, about condoms, health, even sex.

That would be interesting because neither party would end up being able to control people's sexual behavior in the ways they might wish. If any of these technological solutions can reduce HIV transmission, any incentive to use condoms or adopt any of the other strictures of 'safe sex', imagined or otherwise, will disappear.

I don't think anyone seriously believes HIV will just be wiped out in the forseeable future. Sadly, HIV transmission is going to continue to be high enough to infect huge numbers of people, but mainly in developing countries.

There is a lot of enthusiasm for something that looks like a solution, preferably just one single measure, rather than a combination of measures. Sidibe calls 'treatment as prevention' a game-changer, but it might also result in the almost total irrelevance of these two vast institutions.

Now is not the time to start backtracking on condoms. HIV is a matter of health, something neither of these institutions know anything about. We badly need an institution that can represent the health related interests of people, especially poor people living in developing countries. We don't need any more vested interests stealing the health agenda. So let's kiss the Vatican and UNAIDS goodbye and start working on HIV.

Sunday, May 29, 2011

I'm still trying to reconcile two claims from UNAIDS: the first is that 80% of HIV transmission is a result of heterosexual sex in African countries (in most non-African countries it's mainly a result of male to male anal sex and intravenous drug use). An estimated 18% of transmission in African countries is from mother to child. And only the remaining 2% is a result of unsafe health care.

Evidently, non-UN approved hospitals do not take all the necessary precautions to prevent accidental exposure to contaminated blood, nor can they be guaranteed to use new or sterilized equipment. The 2% figure estimated (and it is an estimate, no empirical data has ever been made available to support it) is so low, it can be assumed that only the kind of small clinics found in outlying areas would be responsible for much of it.

So why the need to warn UN employees? There is certainly no danger to them. Or, turning things around, why is there no need to warn Kenyans and other Africans? Most poor Kenyans will rarely see a doctor and much of the treatment they receive will be rushed, performed by badly trained, badly supervised, underequipped personnel, perhaps even people who know nothing about infection control.

Because many people working in health know little about infection control. Many health facilities have few infection control supplies, people who know how to use them or studies to find out if the little available is ever utilized. UN employees are probably in little danger when it comes to health care. But Kenyans face many dangers.

When it comes to infection control, the survey makes especially sorry reading. Only 80% of standalone VCT clinics have both soap and water. The figures for all other types of health facility are even lower, with only 30% or fewer hospitals, health centres and maternity facilities having such basic items.

While 93% of VCT clinics manage to have clean latex or sterile gloves, only two thirds of hospitals and health centres do, and less than 80% of materity facilities do. In fact, only 12% of hospitals have all the basic items needed for infection control. Again, the highest figure is from VCT clinics, where 66% 'make the grade'.

When it comes to supplies of items needed, fewer than 30% of facilities in all categories have all the items and none of the VCT clinics have all of them. It may not be so bad for only 14% of VCT clinics to have supplies of needles and syringes. But only 89% of hospitals, 86% of health centres and 93% of maternity facilities have them.

As for the disposal of contaminated waste, especially sharps, such as needles and scalpels, the majority of facilities don't even have the basics. Sterilization equipment is lacking in many and, even where it exists, there are often no people or equipment to ensure its use. Written guidelines or procedures are also missing in the majority of facilities.

As the Service Provision Assessment itself makes clear, the presence of trained personnel, equipment, guidelines or anything else gives no indication of whether infection control actually takes place, how often and to what extent. If there are any serious breeches, they are unlikely even to be logged, let alone investigated or addressed.

So it seems that UN employees probably do need to be warned. But if so, ordinary Kenyans and other Africans are in far greater danger than pampered foreigners who travel in air conditioned vehicles and have access to some of the best facilities and expertise in the world, and that's not just in health care, either.

Kenyans and other Africans need to be aware that the state of their health facilities is such that their safety from blood borne and other infections is most definitely not assured. Kenyan hospitals are shabby, understaffed and underequipped. It is not clear how much HIV (or other diseases) have been spread by health care procedures because the matter has never been investigated. But it is time to investigate now.

The figure comes from one of Gates' sick-making speeches about Nora's goat, Tommy's piles or some happy, healthy (but African) toddler's ambitions to be prime minister. But behind the sugar coating there is, apparently, a pill; a pill to cure all of Africa's problems.

You might think that pill is GMO, but that's just one of a range of pills that have something in common: intellectual property rights have that not expired.

The strategy starts with "Innovation in seeds [which] brings small farmers new high-yield crops that can grow in a drought, survive in a flood, and resist pests and disease".

Some comments are in order. The majority of crops that have all, or even any of these advantages, are not genetically modified. So, no sugar for them. And these crops, whether GM or otherwise, are not developed, despite Gates' constant reference to them, for small farmers.

The few GM crops that have any of these advantages, none of them have all the advantages, also have some serious disadvantages, what Gates might call 'challenges'. For example, the seeds cost a lot more than conventionally bred seeds, resistance to pests gives rise to resistant pests, giving rise to further costs, etc. I say 'etc' because no commercially available GM crop has been developed with resistance to flooding or drought.

"Innovation in markets offers small farmers access to reliable customers." Now, what markets would he be talking about? The World Food Program and it's 'Purchase for Progress initiative, supported by Gates, which purchases a proportion of food aid from developing countries, or aims to. Apparently one of the Noras or Tommys quadrupled their income in one year as a result of this program.

Or perhaps Gates is talking about the US and EU markets, which subsidise some of their farmers so heavily that cotton and sugar, for example, can be grown more cheaply in the richest countries in the world than they can be in the poorest? Could the US and EU become 'reliable customers'? As things stand, the EU will cease to be customers as they don't accept any GMO contaminated foods for human consumption. So they say, anyhow.

"Innovation in agricultural techniques helps farmers increase productivity while preserving the environment – with approaches like no-till farming, rainwater harvesting, and drip irrigation." No-till farming may or may not require the use of GMOs. But rainwater harvesting and drip irrigation neither requires nor excludes them. The question is, will the Foundation require GMOs or, at least, crops that involve rich country protectionism, in the form of intellectual property rights? I'm guessing that not a lot of money will be spent on these 'challenges'.

"Innovation in foreign assistance assistance means that donors now support national plans that provide farming families with new seeds, tools, techniques and markets." So the rich countries that are making so much money screwing poor countries are going to suddenly concentrate their efforts on alleviating poverty that they have gone to so much effort to create? Keep dreaming Bill.

Following 'Purchase for Progress', there is now 'Feed the Future', of which Gates is also a keen supporter. And why wouldn't he be, with some of the top names in agriculture and food multinationals behind it?

Bill says his strategy has nothing to do with the "old aid model of donors and recipients". Actually, it has everything to do with the old aid model: it guarantees that the model of giving to people from whom you know you can extort a hell of a lot more will work far better if you also take control of the recipients' means of production. That's what's wrong with GMOs and with Gates.

But according to the Guardian article, the World Health Organization estimates that 10% of global disease could be prevented through the provision of safe water, sanitation and hygiene facilities. That estimate sounds rather low, especially for infant and childhood diseases. But at least it is recongized that conditions such as cholera and guinea worm can not be eradicated without providing people with the basics.

Gates, on the other hand, wishes to sink much of his Foundation's money into a vaccine for cholera and polio, with only dribs and drabs going to WASH. And it's not just the Foundation's money that is involved here. It seems that when the Foundation makes a pronouncement about anything, regardless of its serious lack of understanding of the issues, global policy does likewise.

The massive cholera epidemic currently raging in Haiti is a result of a lack of water, sanitation and hygiene services in the country. This lack is not purely a result of some recent disasters, either. The country has been left dangerously underdeveloped as a result of numerous factors, many of them political. Even if a vaccine was available, people would be unlikely to have received it in Haiti and they would likely have been infected with many of the other water borne diseases that are as debilitating and deadly as cholera.

The author of the Guardian article, Yael Velleman, is a policy analyst at WaterAid. The article also calls for closer cooperation between government departments responsible for health, on the one hand, and water, sanitation and hygiene, on the other. This means that donors and those working in development need to connect these two development themes and recognize that they are interdependent.

So, yes to vaccines and other medical technologies. But without better living conditions, they will make little or no difference to people's lives. WASH must come first because without it vaccines will be useless. If you don't believe me, carry out this quick thought experiment: mix vaccine with water drawn from the nearest source of contaminated water and swallow.

That's 15% who have all items for relevant service areas. When it comes to stocks of infection control items,things little better. While 89% have high level sterilization equipment, bleach and injecting equipment, only half have latex gloves and only 40% have all items in stock. So only 3% of Kenyan facilities have everything they need.

So it's not just TB infection that people need worry about, there are also blood borne infections, such as HIV, hepatitis and bacterial infections, amongst others. But TB is exceptionally high in Kenya considering it is so commonly associated with HIV. Because, while Kenya is fifth highest in Africa for TB burden, HIV prevalence there is a lot lower than in the five highest HIV prevalence countries.

The article on TB makes it clear that even where safety supplies are lacking, health services still have to be supplied. Health personnel and patients face considerable risks of being infected through the health facility and health related procedures, testing, treatment or preventative, rather than through normal person to person contact.

Apparently supply chains, funding, management, theft and corruption have all been blamed for shortages. Drugs also, are said to be in short supply, for similar reasons. Equipment, drugs and other items can even be sold off to private pharmacies.

In addition to shortages of supplies, there is also the problem of use. Even when masks are available they are not always used. Some supplies may be misused, with gloves and perhaps other items being reused. That certainly happens in wealthy countries, where such matters are routinely investigated, so it would be unsurprising if it didn't happen in destitute countries.

Even if injection equipment reuse in Africa was only as high as that in the US, that would mean about 400,000 people could have been exposed. But the number notified, apparently, is zero. Not only do Africans not get recalled under such circumstances, but injection reuse hardly ever occurs in African countries, according to UNAIDS and others. And that is despite the figures from the Kenyan Service Provision Assessment, cited above.

Given conditions in Kenyan health facilities, I think it is fair to say that there is far more scope for hospital transmitted infection there than in the worst US hospital. I can't cite any research to back up that claim because virtually no research has been done on infection control in African countries. And that's what makes me question the figure UNAIDS gives for the contribution of unsafe health care to Kenya's HIV epidemic, 2%. Where is their research?

Monday, May 16, 2011

The brief summary at the end of an excellent article on 'Biological Factors that May Contribute to Regional and Racial Disparities in HIV Prevalence' really gets to the point about how HIV prevention should be approached, but generally isn't:

Instead, it is generally assumed that HIV transmission is driven by "stigmatizing socio-behavioural factors such as sexual concurrency or promiscuity, partner violence and so on." This article emphasizes that "biological factors such as endemic co-infections and immunology also play a key role."

The authors warn against blaming affected communities and individuals, something the HIV mainstream have been guilty of while at the same time, rather perversely, warning those in high prevalence communities that they should avoid stigmatizing attitudes. The highest prevalence figures are found in a handful of African countries and in specific regions in some countries.

Occasional mention is made about how inefficient heterosexual sex is when it comes to transmitting HIV, but without any logical conclusions being drwan from that fact. While the probability of transmission resulting from penile-vaginal sex appears to be higher in African countries, such transmission is still "the rare exception rather than the rule."

Co-infections with diseases common in African countries, such as TB, malaria (see also this abstract on malaria as a co-factor in HIV transmission) and various kinds of parasitic conditions may increase transmission by those infected with HIV and increase susceptibility in those uninfected. While it has been recognised that could treating these conditions would reduce transmission, no clinical trials have assessed the impact this might have.

Similar remarks apply to various sexually transmitted infections (STI). But while some trials have looked at reducing STIs as a means of reducing HIV transmission, factors such as non-sexual HIV transmission, perhaps through the STI treatment itself, may not have been taken into account. So not enough is yet known about this kind of intervention.

Male circumcision is discussed and the authors mention that HIV prevalence is higher in a non-circumcising population in Kenya's Nyanza's province. However, they don't mention that there are non-circumcising populations in other countries where HIV prevalence is lower than in circumcising populations.

Also, low HIV prevalence is often correlated with female genital mutilation (FGM), even in Nyanza province itself. The Luo tribe may not circumcise their men, but they don't circumcise their women either. Whereas in tribes that circumcise men and women, such as the Kisii, HIV prevalence is lower than national prevalence. Other tribes that practice FGM, such as the Somali, have even lower HIV prevalence than the Kisii.

Personally, I am opposed to FGM, but the arguments for male circumcision seem equally unconvincing. Some even claim that male circumcision reduces the number of Langerhans cells, which HIV targets. But there are Langerhans cells in the vagina as well and no one would argue that parts of it should be surgically removed to reduce susceptibility to HIV infection.

But if you are opposed to the view that Africans have extraordinary and probably animalistic sex lives, that they care little for their own health and welfare, or for that of their partners and their children, you need to read the above article.

It remains to be seen whether funding for the number of people currently on treatment will be doubled, especially as the costs of treatment go way beyond the costs of antiretroviral drugs, which have attracted much of the funding so far. And many donors are reluctant to even keep funding at its current levels.

In addition, in some countries, a very high percentage of new HIV infections occur in stable relationships. But many of these infections occur where neither partner was previously infected. This is what gives rise to concurrency in the first place. But it is not always clear how or why some people are infected when their partner is not.

Of course, some instances may be simply a matter of one partner either having a sexual relationship with someone who is not their partner or being infected in some other way. But other instances are not so easily explained away. In some countries, about half of these occurrences involve women being infected, but not by their partner, the other half men.

Anyone can speculate about the sexual behavior of people who become infected, but many years of studies in many countries involving tens of thousands of people show that HIV transmission is not very closely correlated with sexual behavior that is considered to carry a high risk of HIV infection.

Often, those who use condoms the most, have the fewest sexual partners (sometimes none at all), have the fewest 'risky' sexual experiences and know all they need to know about 'safe' sex appear to be the most likely to be HIV positive. While certain people are being infected sexually, it is by no means clear that this is the main route of infection in other groups.

So HIV treatment is vital for HIV positive people and it may also prevent infection in some scenarios. But it is by no means enough to ensure that HIV transmission levels are lowered to a position where HIV will become a thing of the past. The very fact that so many people are still being infected years after antiretrovirals have been available to millions of people shows that prevention needs to include more than just treating greater numbers of people and treating them earlier.

And not really knowing how most people became infected in the first place is a big gap in our understanding. There is quite an absurdity in thinking that we can make a serious dent in the worst HIV epidemics when we don't really know why so many people are becoming infected, apparently sexually, with a virus that is relatively difficult to transmit sexually.

The news is good for HIV negative people in discordant relationships, but not for HIV negative people who are not in discordant relationships. And while HIV positive people need treatment, many might still question how they became infected in the first place when their partner is not infected. Prevention has received very little attention so far, so let's not allow the scaling up of treatment to deflect attention even further.

Of course, many 'studies' and articles don't declare their interests and it is beyond the scope of most people to figure out that much of what is available is profoundly biased. But where funding sources are declared, there is unlikely to be any close connection between the authors and the GMO industry.

A common tactic when writing about GMOs is to use some kind of scare story that has been put about by a media that sees news as a form of entertainment, rather than a source of potentially vital information. One of these scare stories is about GMOs 'saving' humanity from disaster, especially where shortages of food may be involved.

There are also claims about GMO crops giving higher yields than conventionally or organically bred crops. Often, slight increases in yields are only temporary. More frequently, higher yields are not realized in real-life situations. Agricultural inputs, including the seeds, are far more expensive. And quantities of fertilizer and pesticides required have tended to creep up until the soil and the water are seriously contaminated and resistance results in GM crops ceasing to be feasible.

Despite the industry's lack of success in producing anything that performs better than conventionally bred seeds, 'drought resistant' corn is being approved by the US Department of Agriculture. The destructive tactic of GMO manufacturers, designed to make farmers entirely dependent on the manufacturer, is also being championed by well known philanthropist, Bill Gates, who can't resist anything where intellectual property is involved.

The majority of Tanzanians live in rural areas and depend directly on agriculture for their food and their income. The imposition of GMOs would wipe out the biggest source of employment and subsistence in the country. It would also destroy the country's ability to sell their products in Europe, one of their biggest markets. The only people to profit from GMOs are those connected with pushing them; everyone else loses out.

A striking similarity between both cholera and HIV is that they spread in countries which were, and continue to be, especially vulnerable. Haiti was already vulnerable before the recent earthquake and hurricane, but things became far more acute afterwards. And the countries with the worst HIV epidemics were vulnerable when the disease began to spread rapidly, for example, most sub-Saharan African countries, or became vulnerable some time later.

The spread of HIV in Eastern European countries is likely to have been facilitated by the breakdown of healthcare services that were available to all during the Soviet era. And in some African countries, the spread of HIV is thought to have been contained in countries that were at war, but that it spread rapidly once peace returned. This phenomenon has not been researched thoroughly but the fact that most health facilities closed during times of severe unrest may have been a factor.

Whether UN personnel from Nepal introduced cholera to Haiti may still be an open question. But the fact that it has infected, and continues to infect, so many makes it clear that people do not have access to adequate supplies of clean water and to effective sanitation facilities. It's the failure to provide people with these vital services that results in high morbidity and mortality, not the mere presence or absence of some pathogen.

Richard Evans' article is as tame as you would expect an article about public health to be in a newspaper whose development section is funded by the Gates Foundation. The foundation is keen on fighting diseases like cholera (and HIV) with vaccines, rather than on addressing the conditions that allow diseases to reach epidemic levels in the first place.

South Africa's ANC may have been wrong in their belief that HIV does not cause AIDS, but not completely wrong about it being part of a white supremacist plot. The Truth and Reconciliation Committee did reveal that the disease was sometimes spread deliberately by HIV positive people, paid to have unprotected sex with HIV negative people. And the public was right to be suspicious of AZT, considering early attempts at using it to treat AIDS killed most patients because the dose was far too high.

Thabo Mbeki may have been wide of the mark in denying the connection between HIV and AIDS but he was not wrong to object to Western stereotypes about African sexuality. These stereotypes are, in fact, the state of the art when it comes to HIV theory. HIV 'prevention' policy still relies entirely on the 'behavioral paradigm', the view that HIV is almost always transmitted sexually in African countries.

Evans' analysis is superficial: you don't need to be a scientist to spot racism. The behavioral paradigm requires the view that Africans (and not non-Africans) have inordinate amounts of sex, with lots of people, and they care little for their own health and welfare or that of their partners or families. Even this history professor should be able to spot that this is not science, it can not be supported by evidence, and all the existing evidence to the contrary has yet to shift adherence to the paradigm.

Thabo Mbeki was not the leader in other African countries where HIV prevalence was higher than that in South Africa, nor in other countries where millions of people are infected. What Mbeki did was wrong, but that doesn't make it right to base public health policy on a crude prejudice, whether that prejudice is against Africans, women, men who have sex with men, injection drug users or any other group.

Evans may have a point about one thing: "Governments and politicians are frequently driven to choose the science that best serves their interest, or their ideological standpoint". But let's not blame science for the fact that the top people in the HIV industry, fronted by UNAIDS, believe something for which there is no evidence for and a lot of evidence against.

Current levels of HIV transmission are not related to bad science, misuse of science or ignorance about science. They are caused by the use of prejudice in the place of science. And it may be wrong to conclude that this is done so that some very rich pharmaceutical companies will get a lot richer. But they definitely will get a lot richer. The problem is not a little bit of dishonesty here and there getting blown out of proportion. The problem is that science developed purely for use by the rich and powerful will ignore or deny anything that is inimical to the interests of the rich and powerful.

While everyone accepts that such infections occur, UNAIDS and other institutions deny that HIV is very likely to be spread this way. It would be odd if that were the case, particularly in high prevalence countries, where health facility conditions are appalling. But any public mention of hospital acquired infections is better than the constant denial that HIV could be transmitted this way when it clearly can.

At 1.9%, Ghana has much lower prevalence than East African countries, where it is three or four times that level, or Southern African countries, where it can be 10 to 15 times higher. But even low prevalence countries can experience rapid increases in HIV transmission if it gets into health facilities and is not identified quickly and eradicated.

HIV theory has never adequately explained how generalized epidemics can occur. These are epidemics where the virus is transmitted widely among the population and not just in specifically high risk groups, such as intravenous drug users and men who have sex with men.

People who are not in these groups are at low risk of being infected because heterosexual sex is a very inefficient mode of HIV transmission. But there are several countries in Africa which have a generalized epidemic; in fact, the majority of people infected face only a very low risk of being infected, yet they are infected in huge numbers.

The standard reflex (it can't really be called an argument) from UNAIDS and the rest of the HIV industry is that Africans have superhuman levels of sex with many lifetime partners, many of whom overlap with each other. In addition, Africans care little about their own health and welfare, or the health and welfare of their partners and family members.

Billions of dollars spent on wagging fingers at Africans about how much sex they should have, with whom, what kinds of sex, etc, has had little influence on sexual behavior, although there are wild claims of success. But even where levels of sexual behavior have been assessed, this has never explained the generalized nature of the highest prevalence epidemics, all of which are found in African countries.

However, this hasn't dented the confidence of UNAIDS and others in the industry in the merits of continuing to insist that Africans have eye-watering levels of sex. After all, there are some very expensive pharmaceutical products available now and the many rich countries seem willing to spend billions, perhaps even trillions, on doling out these drugs, regardless of how much or little influence this has on HIV transmission.

Giving drugs to people who are HIV positive doesn't offer pharmaceutical companies the sort of profits they want. Only a few million more people every year are put on treatment using current guidelines. And even though those guidelines have been changed to help the pharmaceutical industry out, the few tens of millions of people who are HIV positive or who will be infected in the next 20 or 30 years is just not enough to satisfy the industry.

If the probability of a HIV positive man infecting a HIV negative woman is estimated at about 1/500 and that for a HIV positive woman infecting a HIV negative man is 1/1000, all HIV positive people would need to have sex at least every single day, perhaps twice a day, with a lot of people, for up to 10 years.

We know that most people don't have sex that much, nor do most people have that many partners (though some do, not just in Africa) but we have been conditioned to accept figures like how many people each HIV positive person must infect to explain high prevalence figures. And the prejudices about Africans are rarely questioned.

And that's just great for the pharmaceutical industry. Because it has been suggested that if everyone in high prevalence countries is tested at least once a year and put on antiretrovirals immediately, this will cut transmission to the extent that the virus will be almost eradicated in a few decades. This strategy is called 'test and treat' or 'treatment as (or 'is') prevention'.

Even better, some other genius has come up with a strategy called pre-exposure prophylaxis (PrEP), whereby HIV negative people said to be at high risk of infection (from low risk sexual behavior) are put on antiretrovirals, which is said to reduce the chances of their being infected. And perhaps this works, to an extent. The worry is about putting people on these drugs when their risk of infection is very low.

But the market for drugs could now run into hundreds of millions, perhaps many hundreds of millions of people.

So before trying to maximize profits for these pharmaceuticals, it would be worthwhile identifying the exact contribution of all known types of both sexual and non-sexual transmission before putting hundreds of millions of people on drugs. It is not true that each HIV person infects seven more, not sexually, anyhow. If you believe that, you should think about why you do, and whether it could really be true.

Pakistan's epidemic is considered to be 'concentrated', that is, the majority of infections are among members of high risk groups, such as intravenous drug users and men who have sex with men. It has been suggested that the epidemic is 'in transition', but prevalence might just as easily be lower than the estimates would suggest.

There are references to "indiscriminate transfusion of unscreened blood" and "unsafe injecting practices in formal and informal healthcare settings". If these are true, then HIV can not be truly said to have penetrated the country's health services. Those types of transmission would spread the virus very quickly.

Despite the lack of conclusive evidence, it is also estimated that over 50% of HIV transmissions are through heterosexual sex. This could be compared to the 80% (sometimes 90%) estimated by UNAIDS for heterosexual transmission in African countries. The two estimates should certainly be treated with equal skepticism.

It might also be wondered how Pakistan could report indiscriminate transfusion of unscreened blood and high levels of unsafe injecting when these modes of transmission are said to be almost non-existent in African countries. Are Africa's health services so much more advanced than those available in Pakistan? And if they are, why are UN employees warned not to use them? Why do rich Africans opt for medical care in Western countries?

Transmission rates in Pakistan attributed to intravenous drug use and male to male sex are comparable to those found in African countries. But in Pakistan, 27% of transmissions are said to be due to undetermined origin. In African countries, none are so attributed. Epidemiologists much be far more efficient in African countries.

So, aside from having very low prevalence in Pakistan, another stark difference is that in Africa, far more women are infected than men. In Pakistan, it's the other way around, where "86.8 % of reported HIV positive cases are found to be men". Given that probability of transmission from women to men is said to be about half that from men to women, the contribution of heterosexual transmission should be relatively low, certainly lower than 50%.

The differences found in HIV epidemics in Pakistan and, say, South Africa (prevalence 18.1, ie, 181 times higher), are enormous. So enormous that you might ask if it is the same virus that is being referred to as 'HIV' in both countries. My suspicion is that it is the same virus, but we are being lied to about the respective contribution of non-sexual transmission in African countries. Which may be good news for Pakistan, but not for African countries.

However, I'm happy to hear that Joe Karaganis and others have spent three years researching the issue and come up with the Media Piracy in Emerging Economies report. But I don't expect that to make much difference to the position of people in developing countries.

It is also worth stressing that intellectual property (IP) protection, one of the most popular forms of trade protection among those who ostensibly oppose trade protection, is not paid for by those who benefit from it; it is paid for by consumers, in rich and poor countries alike. It's like a kind of tax that we pay to protect the interests of the rich. And it can represent well over 90% of the revenue that IP owners receive.

The report is also important in being independent, unlike much of what we read about IP, copyright issues, piracy, counterfeiting, fakes and whatever else industry is currently whining about.

We might think that everyone can do without luxury goods, especially people who are also short of water, food and medicine. However, various multinationals are doing everything in their power to control water, somehow or other, they already control food to a large extent and the drug industry is almost entirely run on profits inflated by IP protection.

There may be a lot of talk from Bill Clinton, Bill Gates, the World Trade Organization (WTO), UNAIDS and others about generic medicines and making drugs affordable. But prices of vital drugs are also protected by the same means as other goods. Even drugs whose cost has 'dropped' from the astronomical thousands of dollars per year to not much more than 100 dollars, are protected. The ultimate price charged is 100% controlled by the rich and powerful.

Therefore, the 'South African Generic Medicines Association' may sound touchy-feely enough, what with the 'African' and the 'generic' bits. But it is as much part of the pharmaceutical industry as AVAC or any of these other front groups that claim to be trying to keep costs down and make pharmaceutical products more accessible.

And the aid money going towards overpriced generic drugs is effectively another subsidy for those who ostensibly despise subsidies. This is money that could be better spent on the care people need, beyond the mere distribution of drugs, nurses, doctors, other health personnel and much else. But it is not the needs of HIV positive people that are being served here.

Incidentally, de Lay's speech mentions what he considers to be three areas of discussion, HIV prevention, treatment and health delivery. In reality, all three of these refer to drugs, to be paid for by aid money. To date, a relatively small percentage of HIV spending has gone towards prevention, but the industry has agreed that putting more people, HIV positive and negative, on drugs will prevent HIV transmission. And health delivery may sound like more than drugs, but it isn't really. Just read the speech.

It's wonderful how the interests of UNAIDS and the HIV industry as a whole now matches the interests of the global pharmaceutical industry. In fact, UNAIDS' HIV strategy can be summed up in one word: drugs. You can waste a lot more words on it, and you can be sure that UNAIDS and others will, but in the end, drugs are it.

De Lay advocates TRIPS (Trade Related Intellectual Property Rights), TRIPS Plus, Economic Partnership Agreements (EPA) and all sorts of other institutions and instruments that only point to one thing: intellectual property and the protection of the very rich against the very needy. The consortium of partners includes the wHO, the World Bank, the Gates Foundation (financed by IP protection) and a few others.

So it's official: the entire HIV industry, fronted by UNAIDS, is run by and for big pharma, and much of the aid industry will continue to subsidise and represent the interests of other industry sectors. The whole pretense of humanitarian motives can now be abandoned, as no one was fooled anyway. But, more worryingly, few seem to object to this either.

If having massive natural resource potential made a country rich, quite a few African countries would be very rich indeed. Tanzania has more gold than most countries, more uranium, lots of nickel, coal and various other resources. But it's one of the poorest countries in the world. No amount of discovery will make it richer, and may make it poorer.

This is for the simple reason that their resources are systematically stolen by other countries and multinationals. The process is not called stealing, it is called 'partnership', 'investment', etc, even 'development'. But the vast majority of Tanzanian people, and the country as a whole, gain little or nothing from their resources and they lose almost everything that should belong to them.

Several articles rant on about coal but only 12% of Tanzanians have access to electricity. The country is no more likely to see a rapid increase in access to affordable electricity as a result of coal mining that they were likely to see economic improvements when foreign companies came in to mine gold. Earnings from gold exports continue to rise, but it is not Tanzania that is earning much.

Meanwhile, a handful of Tanzanians may be getting rich (or richer), while tens of thousands of artisanal miners are put out of their jobs. Even indigenous companies who would like to mine gold, coal, uranium or anything else are unlikely to be able to compete with the benefits that foreign companies receive.

Lithium, used in batteries for electric cars, is needed in increasing quantities. Many of these attempts to reduce carbon emissions in rich countries will increase carbon emissions in poor countries, perhaps even resulting in a net increase, globally. And environments in countries that are rich in resources will also be seriously threatened.

Calling for Tanzanians, and the country as a whole, to be allowed to benefit from the exploitation of their natural resources is not a call for exploitation to cease. It is a call for large scale, internationally sanctioned theft to cease and for Tanzanians and other Africans to benefit from what is, after all, their property.

This pseudo-strategy involves testing 'all' (the figure hoped for is 80%) sexually active people about once a year, or possibly more often. But only three countries in the world have more than 20% prevalence and only 9 have more than 10%. They had better be very accurate about which 80% of the population they succeed in testing, every year.

Also, the industry usually characterizes HIV as a sexually transmitted infection, although it is not always transmitted sexually and might not even be primarily sexually transmitted. But it's the party line and it's paid off very well so far. Talk about sex will get you money, talk about non-sexual transmission, especially through unsafe healthcare, will get you branded as a denialist or some kind of crank.

But even if you accept the behavioral paradigm, the view that HIV is almost always transmitted sexually (in some developing countries, but certainly not in developed countries), you might notice that the industry has always been very bad at saying exactly who is most at risk. It might seem obvious that those who have most 'unsafe' sex are most at risk, but sex worker populations often have low HIV prevalence figures.

Indee in some countries, sex workers plus their clients plus their clients' partners make up a relatively small contribution to the country's overall epidemic. The largest contribution in many mature epidemics, such as Uganda's, appears to come from people in a stable relationship who mainly engage in low risk sex.

So the industry is in the ironic position of having to target those among whom risk of sexual transmission is low, if they are really going to have any impact through their proposed strategy. In fact, the industry will have to target pretty much all sexually active people, partly because they don't know who the people most at risk are and partly because those who are not at much risk at all appear to be contributing most to some epidemics.

There's a contradiction in there somewhere. But as long as it sells drugs and sales rise every year, the industry will not be complaining. Little attempt will need to be made to figure out how HIV is being transmitted and nothing will be done to reduce transmission by actually addressing causes.

The process will simply involve finding people already infected, putting them on treatment, going through the testing process every year and claiming that a whole lot more would have been infected if the strategy hadn't been implemented.

Oh, and don't worry about evidence: the plan is "based on mathematical modelling". "The model developed assumes a population of very high prevalence which is tested once a year and those found HIV positive started on ARVs immediately; with this early antiretroviral intervention, the model shows that in three decades the new infections would be reduced sufficiently to eliminate the epidemic."

What could disprove this model? Who is discussing the fact that epidemics are the result of conditions that themselves need to be addressed, and not just treated with drugs? And who will wish to answer these questions when there is so much money to be made from ignoring them? Test and treat strategies may seem like they are doing nothing to prevent HIV transmission, but for advocates, not preventing HIV is a form of HIV prevention.

Monday, May 2, 2011

One of the results of the exceptionalization of HIV is that other health conditions end up being ignored, including sexually transmitted infections (STI). Given the HIV industry's obsession with sexually transmitted HIV, it might be expected that STIs such as syphilis might get a bit of attention.

WHO estimates that two million pregnant women are infected with syphilis every year and about 1.2 million of them will transmit the infection to their child. Far fewer children are infected with HIV. And the number of deaths from syphilis during pregnancy is higher than the number of infants infected with HIV.

But, importantly, the review concluded that there are "other compelling reasons why STI treatment services should be strengthened, and the available evidence suggests that when an intervention is accepted it can substantially improve quality of services provided."

Syphilis and many other STIs are preventable and treatable, yet they often seem to be ignored. And it sounds as if they have only received much recent attention because of the possibility that they may reduce HIV transmission.

Surely STIs should be prevented and treated where possible because they are diseases, not just because this might have an impact on HIV transmission? HIV is debilitating and incurable, but other STIs are debilitating and curable.

Whether STI treatment has an impact on HIV transmission or not, people should not have to suffer from them or risk passing them on to their partners and their children, especially when this is entirely avoidable. They have a right to prevention and treatment for all diseases, not just HIV.